Common wisdom may say that
the nation’s EDs are being filled up with the uninsured, but a new study on
EDs asserts that more than 80% of patients seen in EDs have health insurance
and a usual source of health care such as a primary care physician.

The study, which has been
published on-line by the Annals of Emergency Medicine, found that 83%
of ED visits were made by people who had a doctor, a clinic, or who were members
of a health maintenance organization. In addition, 85% had medical insurance,
and 79% had incomes above the poverty level.1

"I think our major finding
is that the individuals who come to our EDs are mainstream Americans who have
doctors and have insurance," asserts Ellen J. Weber, MD, a professor
in the division of emergency medicine at the University of California, San Francisco,
who led the study. Interestingly, the annual National Hospital Ambulatory Medical
Care Survey (NHAMCS) conducted by the Centers for Disease Control and Preven-tion
shows similar statistics: About 17% of ED patients are not insured.2(For information on NHAMCS, see resources below.)

That statistic has significant
implications for ED managers, and in fact, that possibility was one of the reasons
Weber undertook the study.

"We thought that policies
that affected EDs were somewhat impacted by what we believed were misperceptions
of who visits EDs — i.e., the uninsured, the fringes of society," she says.
"And as a result, the EDs were not getting the staff or the funding they needed
because they were not seen as places where mainstream Americans went," she explains.

The data on which Weber
based many of her findings was not an ED study, but rather a household survey
conducted by the Washington, DC-based Center for Studying Health System Change.3
"It looked at the use of health care — health status, age, insurance — and then
what health care resources they used [i.e., EDs]," she adds.

"That allowed us to decide
whether someone who had certain characteristics was more or less likely to use
the ED." Another major source of the study, Weber says, was NHAMCS.

She asserts that these
findings should have an impact on the way upper management views EDs — specifically,
the amount of funding they receive.

"Upper management needs
to recognize that ED managers and their staffs need the same level of attention
that people in other parts of the hospital are getting — especially with the
overcrowding and worry about transfers [we are facing]" she insists. "But, for
example, elective surgeries are prioritized over emergency patients because
[the ED] is thought not to be there for the hospital’s bottom line."

That thought is wrong,
Weber says. "The patients who go to the ED are sicker, probably have a very
legitimate reason to be there, and should have at least equal priority
for the beds," she says. "They are not a drain on the financial system
of the hospital."

The study’s findings, Weber
argues, could be used to affect how ED managers argue for their budget, or compete
for who gets the next bed. "They can argue, Our patients are also part of our
mainstream system — they are not just people who came out of the park, and if
they do not get equivalent priority, they will go somewhere else, and we’ll
lose them in the tertiary care system,’" she suggests.

You might think that ED
physicians in border states such as Texas, where illegal immigrants make up
a significant portion of the population, would perceive a different reality
than the one portrayed in Weber’s study — and you’d be right.

However, Claudie Jimenez,
MD, associate professor of surgery at the University of Texas Southwestern Medical
Center at Dallas, does not reject Weber’s findings outright. "While the numbers
of the uninsured do continue to rise, the problem of ED overcrowding is much
more complex, and this article speaks to this issue," she says.

Jimenez works in a large
urban county ED. "While the majority of our patients are uninsured, many patients
who have coverage still come to the ED for care," she explains.

In a study the facility
conducted in 2001, 63% of patients without insurance said they preferred to
use the ED as the primary source of care, and 40% of patients with private insurance
also preferred to use the ED.

This survey was conducted
among patients who presented to the ED with congestive heart failure, diabetes,
or hypertension, Jimenez says. These are chronic conditions that require routine
maintenance care, she notes.

"These patients may have
exacerbations of their disease that requires emergent intervention and may not
be able to be managed in an ordinary primary care office, or their condition
necessitates an admission to the hospital," Jimenez says. "Only 29% of our surveyed
population called for an appointment with a primary care physician before presenting
to the ED for care."

While it is believed by
some that a large undocumented immigrant population is putting a significant
strain on health care services, especially in border states, actual numbers
are very hard to come by, Jimenez adds.

"While the lack on health
care coverage is an important issue that needs to be addressed, ED overcrowding
is more likely the direct result of a severe shortage of inpatient beds for
an aging patient population with chronic conditions," she concludes.

References

1. Weber EJ, Showstack
JA, Hunt KA, et al. Does lack of a usual source of care or health insurance
increase the likelihood of an emergency department visit? Results of a national
population-based study. Ann Emerg Med 2005. (This article has been published
on-line and is available for download free at: www.acep.org.
Click on "Annals of EM" on the right side of the page. Next, on the left side
of the page, click on Mosby’s web site. At press time, it was scheduled to be
published in the January 2005 edition of Annals of Emergency Medicine.)